DOG�S REGISTERED NAME

							Club Name: GPGRC and CVGRC                                                Date: June 21, 2012
  Send Entries to: Grace Samios, 1622 Lakeview St., Jamestown, PA 16134 Fee $60
 A:___________________ B:____________________C:___________________
    Q NQ DQ                           Q     NQ DQ                           Q     NQ DQ



  DOG’S REGISTERED NAME


                                                           ENTRY FEE
  SEX  MALE  FEMALE
                                                           ENCLOSED $
   ALTERED
  ENTER NUMBERS HERE FOR                                   DATE OF BIRTH

   AKC REG
   CKC REG                                                PLACE OF BIRTH
   ILP NO.                                                 USA  CAN  OTHER
  PERMANENT ID NUMBER ENTER HERE
   MICROCHIP  TATTOO  DNA REG.

  BREEDER


  SIRE


  DAM


  OWNER


  OWNER’S ADDRESS


  CITY, STATE (PROV), ZIP OR POSTAL CODE


       THIS DOG WAS ENTERED IN A PREVIOUS CCA EVENT (There is a limit of 6
  Evaluation tries to earn a CCA title. Advise the Secretary of any previous Evaluations.)
  I certify that I am the actual owner of the dog, or that I am the duly authorized agent of the actual
  owner whose name I have entered above. In consideration of acceptance of this entry, I (we)
  agree to abide by the regulations of the GRCA governing this event, and by any additional rules
  and regulations appearing in the premium list for this event, and further agree to be bound by
  the Agreement printed on the reverse or opposite side of this entry form. I (we) certify and
  represent that the dog entered is not a hazard to persons or to other dogs. This entry is submitted
  for acceptance on the foregoing representation and agreement.


  _____________________________________ ______________________________
  Signature of authorized Owner or Agent Phone Number

  Email Address:

                             CCA OFFICIAL ENTRY FORM
      I (we) agree that the club holding this event has the right to
refuse this entry for cause which the club shall deem sufficient. In
consideration of the acceptance of this entry and of the holding of this
event and of the opportunity to have the dog evaluated, I (we) agree to
hold the GRCA, the host club, their respective members, directors,
officers, agents, secretaries, committee members, evaluators, and the
owner/lessor of the premises, and any provider of services at the
event (and any agents, volunteers or employees of the same) (the
"Released Parties"), all harmless from any claim, loss or injury which
is alleged to be caused directly or indirectly to any person, dog by the
act of this dog, or its owner or agent, while in or about the event
premises or grounds or near any entrances thereto; and I (we)
personally assume all responsibility and liability for any such loss or
claim; and I (we) further agree to hold all of the Released Parties from
any claim, loss, injury or damage to the dog or its handler, owner or
agent.
      I (we) acknowledge that any evaluation, measurement or
comment, whether written or oral, made at this event regarding the
dog is not binding upon, and does not affect in any manner, the dog's
qualifications at licensed dog shows sponsored by AKC or any other
entity licensed to offer conformation shows or performance events for
dogs.
      I (we) hereby assume the sole responsibility for and
agree to indemnify, defend and hold harmless all of the Released
Parties from any and all loss, cost and expense (including legal fees)
by reason of the liability imposed by law upon the Released parties for
damage because of bodily injuries, including death, sustained by any
person or dog, including the undersigned, or on account of damage to
property, arising out of or in connection with my (our) participation in
this event however such injuries, death or property damage may occur
or be caused, and whether or not the same may be caused or may
have been alleged to be caused by the negligence of the Released
Parties.
      I (we) agree that any cause of action, controversy or claim
arising out of or related to the entry, exhibition or attendance at this
event between myself (ourselves), the Host Club, or the GRCA, as to
the construction, interpretation and effect of this agreement shall be
settled by arbitration pursuant to the applicable rules of the American
Arbitration Association, provided, however, that all applicable rules
and procedures of the GRCA must first be followed as set forth in the
bylaws of the GRCA.
      I (we) agree that the results of these evaluations and any
official pictures taken at this event will become the property of the
GRCA and may be used in any breed-related study deemed
appropriate by the CCA Committee of the GRCA.